Montowese Center For Health & Rehabilitation

Based on review of facility documentation, facility policy and interview, the facility failed to designate an individual with the required training and certification to oversee the Infection Control Program. The findings include: Interview with LPN #4 on 10/21/24 identified she became the facility's Infection Control Nurse in February 2024. Interview with RN #4 (Staff Development Nurse) on 10/21/24 at 1:45 PM identified although she is the RN who has the responsibility to oversee the Infection Control program, her involvement and oversight of the Infection Control program is infrequent and the program is handled by LPN #4. RN #4 identified she became the back up for LPN #4 four months ago and has a certificate for Infection Prevention by OSHA, which focuses primarily on accidents such as the prevention of accidental needlesticks in a clinical setting. She stated she chose OSHA's training because it was the least expensive. Interview with RN #5 (Corporate Clinical Infection Control Nurse) on 10/23/24 at 9:30 AM identified she was not familiar with the OSHA certification for infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure the 2-way call bell system was functioning. The findings include: Observation on 10/23/24 at multiple times throughout the day while accompanied by the Director of Maintenance and the BFSI identified the facility's 2-way communication system call bell failed to function properly. An interview with the Director of Maintenance on 10/23/24 at 7:13 AM indicated that he started 3 weeks ago at the facility and was aware that there was a problem with the 2-way call bell system for the residents. The Director of Maintenance indicated that there are rooms that the 2-way call bell system does not work. The Director of Maintenance indicated that the 2-way call bell system does not work in some rooms because the parts are no longer available, and he would have to replace the entire call bell system. The Director of Maintenance indicated the entire second floor 2-way call bell system does not work. The Director of Maintenance indicated the nursing staff can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #43) reviewed for care planning, the facility failed to ensure resident care conferences were completed quarterly, that the resident was invited and attended, and the resident care plan was updated quarterly. The findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and left non-dominant side, aphasia, cognitive communication disorder, and adjustment disorder with mixed disturbance of emotions and conduct. Interdisciplinary Care Planning Meeting document dated 2/19/24 failed to identify if Resident #43 had participated in the care plan process or attended the care plan meeting. Care Plan Meeting Attendees were Resident #43's representative and staff from MDS, social services, and dietary. Interdisciplinary Care Planning Meeting document dated 5/16/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #50) reviewed for falls, the facility failed to ensure interventions were in place after a fall with major injury, and failed to ensure that 1:1 supervision was provided during meal time per the physician's order. The findings include: Resident #50 was admitted to the facility on [DATE] with diagnoses that included dementia, dysphagia, and difficulty walking. A physician's order dated 5/2/24 directed Resident #50 required 1:1 supervision with meals for safety and focus to task. The care plan dated 5/2/24 identified Resident #50 was at risk for aspiration due to oral dysphagia. Interventions included providing 1:1 supervision during meals to ensure completion of meals and use of safe swallow strategies. The care plan also identified Resident #50 had a history of falls. Interventions included to keep the call light within reach. The quarterly MDS dated [DATE] identified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and staff interview for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the residents rights were honored by limiting Leave of Absence (LOA) due to contraband. The findings include: Resident #1 was admitted during 10/2023 with diagnoses that included Traumatic Brain Injury (TBI), paraplegia (paralysis of the lower body), and cognitive communication deficit. The quarterly [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had no cognitive impairment and required substantial assistance for transfers. The Resident Care Plan dated 7/22/2024 identified Resident #1 had short term memory loss and a mobility deficit. Interventions directed to assistance with transfers using a slide board, and to use simple direction communication and verbal cues. Physician order dated 8/31/2024 directed no LOAs. Interview with record review with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interview for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with physician orders. The findings include: Resident #1 had diagnoses that included Traumatic Brain Injury (TBI), paraplegia (paralysis of the lower body), and cognitive communication deficit. The quarterly [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had no cognitive impairment and required substantial assistance for transfers. The Resident Care Plan dated 7/22/2024 identified Resident #1 had short term memory loss and a mobility deficit. Interventions directed to assistance with transfers using a slide board, and to use simple direction communication and verbal cues. Physician order dated 8/31/2024 directed minimal assist with slide board transfers and assist with bilateral lower extremity positioning. Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of four (4) residents reviewed for resident-to-resident altercations, (Resident #2), the facility failed to implement interventions to protect a resident from physical abuse by another resident. The findings include: 1. Resident #2 had diagnoses that included acute respiratory failure, spinal stenosis, and morbid obesity. The quarterly MDS dated [DATE] identified Resident #2 had intact cognition, no behaviors and required extensive assistance with activities of daily living. The care plan dated 3/27/24 identified Resident #2 required help with bed mobility, maximum assist of one staff to move/turn/position body in bed. With interventions that included assistance of two (2) staff with bed mobility, provide resident with a total lift and provide verbal cues, prompts and redirection assistance. A nursing note dated 5/23/24 at 6:47 AM written by LPN #1 identified Resident #2 called her to his/her room for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to assure the medical record was complete and accurate to include an RN assessment after a change in condition. The findings include: Resident #1 was admitted with diagnoses that included Down's syndrome and dysphagia. The RCP dated 5/16/2024 identified Resident #1 was at risk for aspiration due to oropharyngeal (back part of the mouth) dysphagia (difficulty swallowing). Interventions directed to follow feeding guidelines as indicated, have resident sit upright for all oral intake and to monitor for signs of aspiration that may include coughing, fever, and congested lung sounds. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, required set up help for eating, and holds food and had loss of liquid and food from mouth when eating. Physician order dated 5/29/2024 directed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility documentation, review of policy and procedures and interview with facility staff for 11 of 12 residents reviewed for medication administration omissions or delays in administration (Resident #'s 3, 44, 45, 46, 47, 48, 49, 50, 52, 53 and #40) which had the potential for neglect, the facility failed to complete required reporting documentation, investigate why such omissions or delays occurred and take any corrective action, and failed to report to the state survey agency in accordance with the policy and procedures. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the meninges and the brain, epilepsy with intractable status epilepticus, type 2 diabetes, hypothyroidism, essential primary hypertension, heart failure, and atrial fibrillation. Physician orders dated 1/15/23 directed Cyanocobalamin, 1000 micrograms daily (indicated for low hematocrit). A nursing progress note dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility documentation, review of policy and procedures and interviews with facility staff for 8 of 12 residents (Resident #'s 24, 25, 45, 46, 50, 52, 53, and 40) reviewed for medication administration which resulted in medication errors, the facility failed to administer medications in accordance with physician/advanced practice registered nurse orders to ensure residents were free from significant errors. The findings include: 1. Resident #24's was admitted to the facility on [DATE] with diagnoses that included cellulitis, atrial fibrillation. congestive heart failure (CHF) and lymphedema. A physician's order dated 6/23/21 directed Eliquis tablet 5 milligrams by mouth two times a day for atrial fibrillation and Lasix Tablet 40 milligrams, by mouth two times a day for congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 as cognitively intact and required extensive assistance with bathing and dressing.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, and interviews with facility staff for 7 of 7 residents self-administering medication (Resident #'s 54, 55, 56, 57, 58, 59, and 60), the facility failed to conduct a medication self-administration assessment in accordance with facility policy. The findings include: 1. Resident #54 was admitted to the facility on [DATE] with diagnoses that included weakness, peripheral vascular disease, essential hypertension, and acquired absence of the left leg above the knee. A self-administration assessment dated [DATE] indicated the resident was only administering Flonase. Physician orders dated 4/16/24 directed Methadone HCL 5 milligrams (mg), 50 mg daily for opioid dependence. A MDS assessment dated [DATE] identified the resident had a BIMS of 15. During an interview with the Nursing Supervisor on 5/3/24 at 5:00 A.M., s/he identified the nurse assigned to Resident #54 provides the Methadone to the resident at 6:00 A.M. and the resident self-administers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview the faciity failed to ensure recent survey activites were accessbile to residents and the public. The findings include: Observations during tour of the facility on 4/18/2024 at 8:00 AM identified a note taped on the counter of the reception desk that read Please see the Receptionist for Connecticut's Department of Public Health Annual Survey, which is now available for review. Interview with the Director of Nurses (DNS) at 9:30 AM identified that the Survey results are to be available to all and no one should have to ask for the survey results. Further observation identified that the DNS removed the sign from the counter at the receptionist desk. Observations on 4/24/2024 at 8:30, 10:00 AM and 2:00 PM and on 4/25/2024 at 8:00 AM and 2:05 PM identified that the survey results were located on the wall on the receptionist desk. Further observations identified that the results were covered by folders.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview for 2 of 2 residents (R# 5 and Resident #13) that had an increase in weight or had a change of condition, the facility failed to notify the physican of a weight gain or the responsbile person of the change in condition. The findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), hypoxemia, weakness, low back pain and hypothyroidism. Physician orders dated 10/10/19 directed a daily weight and notify the APRN/MD of an increase of 2 pounds in a day or 5 pounds in a week. Subsequent orders dated 10/21/19 and 10/23/19 directed a fluid restriction of 1500 milliliters (ml) daily and a fluid restriction of 1500 ml daily with 11-7 shift: 340 ml, 7-3 shift: 340 ml, and on the 3-11 shift: 630 ml. An assessment dated [DATE] identified a cognitive impairment, required extensive assistance with transfers, continent of bowel function and occasional urinary incontinence. A corresponding care plan dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and procedures and interviews with facility staff, for two of two residents reviewed for discharge planning (Resident #21 and #26 ) the facility failed to provide a safe and comprehensive discharge plan that included education to caregivers regarding the discharged resident's level of support that would be needed and provided upon discharge from the facility or provide the resident with the appropriate medication. The findings include: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included a cerebral vascular accident, myocardial infarction, falls, anemia, weakness, Covid 19, major depression, and post-traumatic stress disorder. A physician's order dated 6/20/20 directed to plan for discharge. A MDS assessment dated [DATE] indicated a BIMS of 15 and the resident required minimal to extensive assistance with dressing and transfers. The discharge Minimum Data Set assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview for 1 resident (R#10) reviewed as a new admission to the facility, the facility failed to have the orders signed timely. The findings include: Resident # 10 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, syncope and collapse, anemia, acute kidney failure and basal cell carcinoma of skin of left upper limb. Review of the Order Summary Report from 10/1/2022 -10/31/2022 failed to identify that the physician had approved the orders and signed the orders. Review of the clinical record identified one Progress Note *NEW* dated 10/13/2022 Facility Discharge, Late Entry APRN Progress Notes. Further review of the clinical record failed to identify admission documentation completed by the physician and/or APRN. Interview and review of the clinical record with RN#4 on 5/2/2024 at 10:45 AM failed to identify admission documentation completed by the physician and/or the APRN within forty eight hours of the residents admission to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of the policy and procedure, and interview with facility staff for one resident reviewed for falls (Resident #6), the facility failed to ensure the fall risk assessment was done at admission in accordance with the policy and procedures. The findings include: Resident # 6 was admitted to the facility on [DATE] with diagnoses that included weakness, systemic lupus, and a history of falls with a recent Cervical 1, 2 and 3 fracture. A resident care plan dated 5/24/21 identified a risk for falls with interventions that included, do not leave in the bathroom unattended, place call light within reach and orient to surroundings. Review of facility documentation dated 6/3/21identified the resident was found on the floor of his/her room at 7:30 P.M. The facility investigation indicated the resident had been last checked at 6:00 P.M. and concluded the resident had independently transferred out of bed. Further review of facility documentation identified an initial fall risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and procedures and interview with facility staff for 2 of 4 residents (Resident #19 and 36) reviewed for non-pressure skin conditions, the facility failed to follow physician orders, failed to document weekly skin assessments for the right 2nd toe and left 4th toe and failed to ensure assistance was provided to ensure the resident had access to his/her scheduled follow up appointment. The findings include: 1. Resident # 19 was admitted on [DATE] with diagnoses which included COVID-19, End Stage Renal Disease (ESRD), atherosclerotic heart disease of native coronary artery, and hypertension. The hospital Discharge summary dated [DATE] identified a necrosis to the 4th right toe and an ulceration to the 4th left toe. The discharge summary further noted a pressure injury to the coccyx (no measurement noted) A nursing admission assessment dated [DATE], 10:55 P.M. identified an open area to the coccyx which measured 0.25 centimeters (cm) by 0.25 cm and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, staff interviews, and facility policy for 2 of 4 residents (Resident #19 and #28) reviewed for skin conditions related to pressure, the facility failed to follow physician orders, failed to document weekly skin assessments for a pressure ulcer noted on the coccyx and failed to follow the policy on the prevention and management of pressure ulcers. The findings include: 1. Resident # 19 was admitted on [DATE] with diagnoses which included COVID-19, end stage renal disease (ESRD), atherosclerotic heart disease of native coronary artery, and hypertension. The hospital Discharge summary dated [DATE] identified a necrosis to the 4th right toe and an ulceration to the 4th left toe. The discharge summary further noted a pressure injury to the coccyx (no measurement noted) Review of physician orders dated 4/27/20 directed facility staff to do weekly wound documentation and hemodialysis three times a week A nursing admission assessment dated [DATE], 10:55 P.M. identified an open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, staff interviews, and review of facility policyand procvedures for 7 of 7 sampled residents (Resident # 1. 5, 9, 18, 23, 29, and 42) reviewed for nutrition and hydration, the facility failed to monitor weights or monitor intake and output in accordance with physician orders. The findings include: 1. Resident # 1 was admitted to the facility on [DATE] with diagnoses that included, type 2 diabetes mellitus, infection of the skin and renal dialysis. A minimum data set (MDS) assessment dated [DATE] identified a BIMS of 15 and the resident can make decisions related to tasks of daily living. The MDS assessment further identified the resident as receiving dialysis. A corresponding care plan which was initiated on 4/29/21 identified a potential for impaired nutrition due to requiring hemodialysis with interventions that included a fluid restriction of 1500 milliliters (ml) per day and to monitor intake. Review of physician orders dated 5/5/21 directed a 1500 milliliter (ml)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of the facility policy and procedure, and interviews for 1 resident reviewed for pain management (Resident #11) , the facility failed to identify and intervene timely for complaints of pain. The findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, influenza, pneumonia, osteoarthritis of right shoulder and a right artificial shoulder joint. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 as cognitively intact and required limited assistance with bathing and dressing and transfer and ambulation happened only once or twice. The MDS further identified the resident reported the presence of pain almost constantly, the level of pain makes it hard to sleep at night and the pain limits day to day activities. The Resident Care Plan dated 12/6/22 and revised 1/3/23 identified Resident #11 had pain and the potential for pain related to chronic shoulder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records for 8 of 8 residents who experienced singficant medication errors (Resident #'s 24, 25, 45, 46, 50, 52, 53, and 40) and review of facility documentation, the facility failed to ensure sufficient staffing on 1/28/23 between 7:00 AM - 11:30 AM to meet the resident's needs. The findings include: Review of the daily census dated 1/28/23 identified a census of 107 residents. Review of the staffing dated 1/28/23 for the 7:00 AM - 3:00 PM shift identified although there were 3 nurses and 1 nursing supervisor assigned to the facility, significant medications were either late or omitted for 8 residents.

Based on review of 2 of 2 personnel files, the facility failed to complete performance appraisals in accordance with the facility policy. The findings include: Review of the personnel files identified the following: 1. Registered Nurse #8 had an effective employment date of 9/29/22. Further review failed to identify a performance review had been completed since the date of hire. 2. Registered Nurse (RN) #9 had an effective employment date of 9/29/22. Further review failed to identify a performance review had been completed since the date of hire. Interview and review of the personnel files with the Chief Administrative Officer on 5/5/24 identified the personnel files for RN # 8 and RN #9 were lacking performance appraisals since the effective date of hire and in accordance with the facility policy and procedure. Review of the Performance Appraisals policy directed in part, Department heads and supervisors will complete performance appraisals upon the following occasions: a. By the end of the first three months of employment; b. Prior to the anniversary date of employment; c. Six…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy and procedures, and staff interviews for one sampled resident (Resident #12) reviewed for hydration, the facility failed to ensure a laboratory test was obtained iin accordance with physician orders. The findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses of anemia, dementia, atrial fibrillation, and hypertension. A Resident Care Plan dated 12/29/20 identified the resident was a fall/safety risk, had a diagnosis of anemia, expereinced an ADL decline, and had a COVID-19 infection. Interventions included transmission-based precautions, vital signs as indicated, reduce and/or eliminate out of room activity unless medically indicated, grooming and dressing, monitor for complications, and encourage to use the call light. Physician orders dated 1/8/21 directed a repeat Basic Metabolic Panel (BMP) was to be obtainied. Review of the clinical record with the DON (Director of Nursing) on 5/9/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy for 1 sampled resident (Resident #12) reviewed for hydration, the facility failed to ensure Resident #12's laboratory results were available in the resident's medical record. The findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses of anemia, dementia, atrial fibrillation, and hypertension. An initial Resident Care Plan (RCP) dated 12/29/20 identified the resident was a fall/safety risk, and had anemia, an ADL decline, and a COVID-19 infection. Interventions included transmission-based precautions, vital signs as indicated, reduce and/ or eliminate out of room activity unless medically indicated, grooming and dressing, monitor for complications, and encourage to use call light. An admission Minimum Data Set (MDS) dated for 12/30/20 identified Resident #12 did not have intact cognition and required set up or clean up assistance for eating and oral hygiene. Additionally, the resident required partial/moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation and interview with facility staff for one sampled resident (Resident #18) who had a diagnostic test ordered, the facility failed to obtain the test in accordance with provider orders. The findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, atrial fibrillation, bradycardia, difficulty walking, and chronic obstructive pulmonary disease. A fall risk assessment dated [DATE] identified a score of 6, with a score of 10 or greater representing a high risk for falls. A resident care plan dated 5/12/19 identified the resident was at risk for falls secondary to being newly admitted to the nursing home. Interventions included a bed alarm, chair alarm, gripper socks while in bed, and placing the call bell in reach. Review of a progress note dated 5/12/19 indicated the resident had an unwitnessed fall. The progress note identified the patient reported s/he hit her head, and vital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interview for 1 of 1 resident (Resident #24) reviewed for dietary preferences, the facility failed to conduct an initial nutritional assessment in accordance with the policy and procedures and/or to assess and establish menu preferences for the resident reviewed. The findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses which included cellulitis, Congestive Heart Failure (CHF), and atrial fibrillation. A physician's order dated 6/23/2021 directed a low fat, low sodium regular consistency texture, with thin liquids consistency diet. In addition, orders dated 6/23/21 directed to obtain a weight on admission and for 4 consecutive weeks post admission then reassess. The admission Minimum Data Set assessment dated [DATE] identified Resident #24 as cognitively intact and required extensive assistance with bathing and dressing. While the resident care plan dated 7/10/21 identified the resident is on a therapeutic diet with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, staff interviews, and review of facility policy for 1 of 4 residents (Resident #19) reviewed for wounds, the facility failed to document weekly skin assessments for the coccyx, right 2nd toe and left 4th toe, and failed to provide accurate documentation in the electronic health record. The findings include: Resident #19 was admitted on [DATE] with diagnoses which included COVID-19, End Stage Renal Disease (ESRD), atherosclerotic heart disease of native coronary artery, and hypertension. The hospital Discharge summary dated [DATE] identified a necrosis to the 4th, right toe and an ulceration to the 4th left toe. The discharge summary further noted a pressure injury to the coccyx (no measurement noted). A nursing admission assessment dated [DATE] at 10:55 P.M. identified an open area to the coccyx which measured 0.25 centimeters (cm) by 0.25 cm and an area on the right second toe with a 0.5 cm x 0.5 cm eschar. A subsequent APRN progress note dated 4/28/20 identified Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview with facility staff, the facility failed to ensure a safe environment. The findings include: Observations on 4/17, 4/18, and 4/19/24 throughout the days identified the pool area in the facility rehabilitation gym was unsecured. Observations identified the rehabilitation gym to be very busy on all days. Addtionally, the pool was noted to be drained with an approximate 4-5 foot drop to the bottom of the pool. Subsequent to surveyor interview with the Maintenance Director on 4/19/24 at 11:30 A.M., the area was noted to be secured throughout the remaining days of the inspection activities.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and facility policy for one (1) of three (3) residents, (Resident # 3), reviewed for abuse, the facility failed to report an allegation of abuse timely to the state agency. The findings included: Resident # 3 diagnoses included Alzheimer's Disease, chronic obstructive pulmonary disease, Type 2 Diabetes Mellitus, anxiety, and agitation. The admission Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #3 had sever cognitive impairment, was frequently incontinent of bowel and bladder, and was dependent with Activities of Daily Living (ADL's). A Resident Care Plan (RCP) dated 3/29/23 identified the resident had an alteration in ADL status and required an assist of two (2) with upper and lower body bathing, dressing, eating, grooming, and toilet hygiene with interventions that included to explain the expected task to the resident, provide privacy, promote dignity, provide incontinent care approximately every two hours and as needed, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and facility policy for one (1) of three (3) residents,(Resident # 3), reviewed for Abuse, the facility failed to complete an investigation related to an allegation of abuse. The findings included: Resident # 3's diagnoses included Alzheimer's Disease, chronic obstructive pulmonary disease, Type 2 Diabetes Mellitus, anxiety, and agitation. The admission Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #3 as severely cognitively impaired, frequently incontinent of bowel and bladder, dependent with Activities of Daily Living (ADL's). The Resident Care Plan (RCP) dated 3/29/23 identified the resident had an alteration in ADL's and required an assist of two with upper and lower body bathing, dressing, eating, grooming, and toilet hygiene with interventions that included to explain the purpose of and expected task, provide privacy, promote dignity, provide incontinent care approximately every two hours and as needed, and to provide a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and interviews for one (1) of three (3) residents,(Resident # 3), reviewed for Abuse, the facility failed to implement a care plan to address the resident's resistiveness to care. The findings included: Resident # 3's diagnoses included Alzheimer's Disease, chronic obstructive pulmonary disease, Type 2 Diabetes Mellitus, anxiety, and agitation. The admission Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #3 had severe cognitive impairment, was frequently incontinent of bowel and bladder, and dependent with toileting and transfers/ Review of the Nursing admission assessment dated [DATE] identified mood/behaviors of anxiousness, withdrawal, uncooperativeness,combativeness, and resistiveness. Review of nursing notes dated 3/15/23 through 3/30/23 identified Resident #3 had several episodes where h/she was combative and aggressive with care. The Resident Care Plan (RCP) dated 3/29/23 identified the resident required an assist of two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for a change in condition, the facility failed to neurological checks after an unwitnessed fall in accordance with facility policy. The findings include: Resident #2 was admitted to the facility on [DATE] at 7:49 PM with diagnoses that included orthopedic aftercare following a surgical amputation, type II diabetes and macular degeneration. The fall risk assessment dated [DATE] identified Resident #2 was at risk for falls. A physician's order dated 12/22/22 directed assist of one for bed mobility and hoyer lift for transfers. a) Review of the accident and incident form (A&I) dated 12/22/22 identified at 3:30 AM Resident #2 was noted on the floor with not witnesses identified. Review of a nursing note dated 12/22/22 at 4:14 AM identified Resident #2 was found on the floor by the Nurse Aid, an assessment was completed by the nursing supervisor and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documentation and interview for two (2) of three (3) employee records reviewed for annual abuse training, the facility failed to ensure certified nursing staff had annual abuse training in accordance to facility policy. The findings included: a) Review of NA #1 employee file on 3/14/24 identified that the last annual abuse training was completed in 2022, the employee file failed to identify completion of abuse training for 2023. b) Review of NA #2 employee file on 3/14/24 identified that the last annual abuse training was completed in 2022, the employee file failed to identify completion of abuse training for 2023. Interview with RN #1 on 3/14/24 at 2:08 PM identified facility policy directed certified nursing assistants to complete their abuse training annually. RN#1 further indicated there were large periods of time during 2022 that the facility lacked a staff development person to oversee and ensure completion of the certified nurse assistant's annual competencies and because of this, the competencies weren't completed as required. Review of the abuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were reviewed for medication administration, the facility failed to follow their established professional standard when transcribing a physician's order, documenting at the time a medication was administered, and administer the correct dated dose of a medication. The findings include: Resident #1 diagnoses included alcohol and polysubstance abuse, dependence on renal dialysis, cirrhosis of the liver and chronic viral hepatitis. The Resident Care Plan dated November 3, 2023 identified that Resident #1 had a diagnosis of alcohol and polysubstance abuse. Interventions directed to monitor the resident's psychosocial status, provide support, and arrange psychiatric services as needed. A physician's order dated 11/4/23 directed to administer Methadone HCL oral solution 5 milligrams (mg)/5milliliters (ml) 105 mg by mouth daily. Review of the November 2023 Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were reviewed for medication administration, the facility failed to administer a medication in accordance with the new physician's order. The findings include: Resident #1 diagnoses included alcohol and polysubstance abuse, dependence on renal dialysis, cirrhosis of the liver and chronic viral hepatitis. The Resident Care Plan dated November 3, 2023 identified that Resident #1 had a diagnosis of alcohol and polysubstance abuse. Interventions directed to monitor the resident's psychosocial status, provide support, and arrange psychiatric services as needed. A physician's order dated 11/4/23 directed to administer Methadone HCL oral solution 5 milligrams (mg)/5milliliters (ml) 105 mg by mouth daily. Review of the November 2023 Medication Administration Record identified the Methadone was administered daily at 9:00 AM. The discharge Minimum Data Set assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for three (3) of three (3) residents (Resident #1, Resident #2, and Resident #3) who were reviewed for intake and output (I/O), the facility failed to record fluid intake for a resident(s) on I & O, the facility further failed to ensure the testing of the glucometer according to facility policy. The findings include: 1) Resident # 1's diagnoses included obstructive and reflux uropathy. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was was cognitively intact, had a suprapubic catheter (tube extending from the bladder to the outside of the body to fascilitate the emptying of the bladder) and required moderate assistance with toileting. The Resident Care Plan (RCP) dated 9/29/23 identified Resident #1 required assist of one with toileting and had a suprapubic catheter related to urinary tract obstruction and chronic urinary retention with interventions that directed to monitor and document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 3 sampled residents (Resident #4 and Resident #5) who were reviewed for parenteral fluids, the facility failed to ensure Intravenous (IV) fluids were implemented in a timely manner. The findings include: 1. Resident #4 had diagnoses that included congestive heart failure and chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had severe cognitive impairment and required (1) to (2) person assist with activities of daily living (ADL)and one person assist with eating. The Resident Care Plan (RCP) dated 10/10/23 identified a potential alteration in nutrition related to diagnoses that included stage 3 chronic kidney disease with interventions that directed to provide 1:1 assistance with meals and provide water at the bedside daily. A physician's order dated 10/4/23 at 11:02 AM directed dextrose 5% and (0.45%) normal saline at 75 cubic centimeters, (cc/hour, measurement of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews, facility documentation and interviews, for three of three sampled residents (Resident #2, #3, and #4) who were reviewed for the administration of the afternoon and evening medications, the facility failed to administer medications at the time ordered and in accordance with the standard of practice, one hour before or after the designated time and for one of three sampled residents (Resident #3) who was reviewed for pressure ulcers, the facility failed to administer a treatment to the coccyx at the time ordered and in accordance with standard of practice and for one sampled resident (Resident #1) who had a central venous access device, the facility failed to change the central venous access device dressing at the time ordered and in accordance with the standard of practice. The findings include: 1. Resident #2's diagnoses included congestive heart failure, diabetes, hypertension, and atrial fibrillation. An admission physician's order dated 9/13/23 directed to administer Torsemide 60 milligrams (mg) by mouth two (2) times a day, Carafate oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, and interviews for 1 sampled resident (Resident #57) who utilized an indwelling catheter, the facility failed to ensure that the resident was scheduled for a consult with a specialized physician was scheduled. The findings include: Resident # 57 was re-admitted to the facility on [DATE] with diagnosis that included retention of urine, urinary tract infection, memory deficit following cerebral infarction. Physician's orders dated 2/4/22 directed Foley catheter care with soap and water every shift and as needed and to irrigate Foley catheter as needed with 60 ml normal saline for blockage or leakage as needed. The APRN's progress note dated 3/11/2022 indicated that no clear diagnosis for the chronic indwelling catheter was found and recommended to follow up with urology to evaluate the appropriateness of a voiding trial. Review of the physician's orders for the month of March failed to identify that an order directing for the resident to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews, review of facility's documentation and interviews for 6 of 11 sampled residents (Residents #24 ,#49, #65, #75, #81 and #300) reviewed for lab services, the facility failed to ensure that laboratory services were available within the facility resulting in the residents being sent out to the hospital to have physician ordered laboratory tests completed. The findings include: Review of facility documentation identified a letter from the facility's former contracted laboratory partner that identified that laboratory services would be terminated on 7/5/22. A review of facility documentation and the transport log from the contracted transport company identified that Residents were transported from the facility to a nearby hospital for physician ordered blood work from 7/5/22 to 7/13/22. Resident #24 had diagnoses that included type 2 diabetes, peripheral vascular disease, congestive heart failure, coronary artery disease, hypertension, and chronic osteomyelitis. Resident #24 was on medications that included digoxin 0.125 daily for heart disease and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of facility's policy, and interviews, the facility failed to ensure two dietary staff had face masks in place that completely covered the nose, mouth and chin to prevent the spread of COVID -19 infection, and failed to ensure that four nursing staff had nails that were at a safe and acceptable length to prevent possible injury and the spread of infection. The findings include. 1. An initial tour of the kitchen on 7/25/22 at 9:10 AM noted dietary assistant (DA #1) sanitizing pots and trays in a three-step process sink. Further observation noted DA #1 had a protective face mask on that was covering her mouth but did not cover her nose. Dietary Director immediately directed DA #1 not to pull the face mask low below her nose and to make sure it covers her nose, mouth and chin. Observation on 7/25/22 at 10:00 AM noted DA #1 DA #2 emptying cups from the dishwasher and DA #1 and DA #2 had protective face masks on that did not cover their noses. Interview with DA #1 at that time identified she was aware that her mask should covered her nose and she immediately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 sampled residents (Residents #202 & #302) reviewed for advanced directives, the facility failed to ensure that advanced directives were addressed. The findings include: 1. Resident # 202 was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes, sleep apnea, other symptoms involving the circulatory and respiratory systems. The admission MDS assessment dated [DATE] identified Resident # 202 was cognitively intact and required limited assistance for bed mobility, walking and supervision for transfers and toileting, independent for eating once set up. The care plan dated [DATE] identified on [DATE] Resident #202 had established advanced directives and wished to receive CPR. Review of Resident #202's clinical record on [DATE] (7 days after admission) at 1:26 PM failed to reflect signed advanced directives indicating the resident's wishes for CPR (cardiopulmonary resuscitation)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review facility's documentation , facility policy review and interviews for 1 of 5 sampled residents (Resident #60) reviewed for pain management, the facility failed to ensure that the physician was notified that Levothyroxine was not available and not administered for 3 consecutive days. The findings include: Resident #60's diagnoses included acute on chronic heart failure, type 2 diabetes mellitus, anemia, multiple myeloma. morbid obesity, hypertension, hyperlipidemia and hypothyroid. The physician's order dated 6/23/22 directed to administered Levothyroxine (used to treeat hypothyroidism) 137mcg by mouth daily. The resident Care Plan (RCP) dated 6/24/22 identified Resident #60 had hypothyroidism with interventions that incluided, administered medication as directed and monitor for sign and symptoms of hypothyroid such as weight gain, cold intolerance, fatigue/weakness and muscle pain. The admission MDS assessment dated [DATE] identified Resident #60 had intact cognition and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident (Resident #12) with a history of elopement, the facility failed to ensure one to one monitoring was consistently completed. The findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included autistic disorder, intellectual disabilities, and adjustment disorder. The quarterly MDS assessment dated [DATE] identified Resident #12 had intact cognition, required supervision for bed mobility, transfers, ambulation and locomotion The physician's orders for the month of July 2022 directed Resident #12 required moderate assistance of one with bed mobility, and transfers. The orders also identified that Resident #12 utilized a rolling walker. A nurse's note dated 7/21/22 at 1:01 PM identified Resident #12 was seen by the nurse at 8:00 AM in the hallway talking to another resident regarding his/her laundry. At 8:30 AM Resident #12 was given breakfast by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and interviews for one of 1 sampled resident (Resident # 45) reviewed for Hospice, the facility failed to develop a comprehensive care plan after a significant change in condition. The findings include: Resident # 45 ' s diagnoses include mild cognitive impairment, anemia, rheumatoid arthritis, and low back pain. Resident #45 ' s Advanced Directive Declaration, Code Status dated [DATE] indicated that Resident #45 does not want resuscitation efforts performed and does not want a breathing tube. The significant change MDS assessment dated [DATE]th, 2022, identified Resident #45 had severe cognitive impairment, required extensive assistance for bed mobility, transfers, toilet use, and bathing, The assessment further identified the resident does not ambulate, required limited assistance with eating and received hospice care. The Resident Care Plan (RCP) dated [DATE] identified Resident #45 was on Hospice level of care with interventions that included,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, facility documentation review, facility policy review and interviews for 1 of 3 sampled resident (Resident #23) reviewed for accidents, the facility failed to ensure that the smoking assessment was done in accordance with the facility's policy. The findings include: Resident #23 was admitted to the facility in August of 2021 with diagnoses that included; aftercare following surgical amputation, anemia, chronic obstructive pulmonary disease (COPD). The Resident Care Plan (RCP) dated 3/21/22 identified Resident #23 smoked and care plan interventions included, instruct resident about the facility policy on smoking, keep all smoking materials locked in the medication room, ascertain resident's wishes about smoking and respect decision. The quarterly MDS assessment dated [DATE] identified Resident #23 had intact cognition, was independent with transfers, dressing, toileting and hygiene. Review of the clinical record identified a smoking assessment was completed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, facility documentation review, facility policy review, and interviews for 1of 2 sampled residents (Resident # 71) reviewed for unnecessary medications, the facility failed to ensure that the recommendations made by the pharmacist after completion of the medication regimen review were addressed timely by the prescriber/physician including timely completion of a baseline AIMS (abnormal involuntary movement scale) assessment. The findings include: Resident # 71's diagnoses in part included generalized anxiety disorder, depression, and delusional disorder. The admission MDS assessment indicated Resident # 71 was cognitively intact, required supervision of one person for bed mobility limited assists of one person for transfer, toileting, and bathing and was able to feed self once set up. The MDS further indicated that Resident #71 received antipsychotic, antianxiety and antidepressant medication daily. A Physician's order dated 6/24/2022 directed to administer Quetiapine Fumarate 100 mg tablet by mouth at bedtime for psyche. A consultant progress note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews, the facility failed to ensure that eye drops were labeled with the date opened and expired IV supplies and solutions were removed and discarded timely. The findings include: On 7/26/2022 at 1:30pm observations of the Unit 2 medication room with LPN#11 identified 29 expired Intravenous (IV) solution [NAME]/Tazo 4.5mg in 100 ml of Normal saline in which the label indicated not to use after 6/9/2022. These expired solutions were stored in a rolling cabinet in drawers with IV solution/medications that were currently being used for other residents. Further observation revealed the IV supplies for general use contained one IV bag of 0.9% normal saline and one IV Bag of 5% Dextrose with 0.45% normal saline neither had a protective covering exposing the rubber access port and had no label indicating the date these bags were delivered to the facility. Further observation of the IV supplies for general use revealed two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy and interviews for 2 employees (NA #1 and NA #2) who did not display an identification badge inclusive of a picture, the facility failed to ensure that the staff members displayed identification badges with their name and picture. The findings include: Observation on 7/25/22 at 9:15 AM failed to identify that NA #1 had an identification badge in place inclusive of name and picture. Interview with NA #1 at the time identified she had been employed at the facility for three years. She indicated that she drove a different care to work that day and had left her identification badge in another car. Interview with the ADNS on 7/25/22 at 9:18 AM identified he was unaware that some of the staff did not have identification badges in place. He further noted that it is his expectation that staff display their identification badge during all working hours. Observation of NA #2 on 7/25/22 at 9:30 AM identified that she did not have an identification badge in place, interview with NA #2 at that time identified that she had been employed at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food safety and for for one of five sampled residents (Resident #39) reviewed for nutrition, the facility failed to ensure a meal was held at an appropriate holding temperature for an appropriate amount of time according to professional standards. The findings included: 1. Observation on 3/2/20 at 10:15 A.M. with the Dietary Supervisor during a tour of the kitchen identified the following: a. There was a garbage can on the right side of the 3-bay sink without a cover leaning against a stack of dishwasher racks with clean coffee cups in them. There was a second garbage can without a cover on the left side of the sink with garbage in it touching against the 5-tier rack with clean pots and pans on it. The Dietary supervisor indicated at the time of the observation the facility never had covers for the garbage cans.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two of three sampled residents (Resident #39 and #103) reviewed for the environment, the facility failed to provide a homelike, neat and well kept resident room and failed to provide storage to accommodate a resident's need. The findings included: 1. Resident #39's diagnoses included weight loss, Peripheral Vascular Disease and Gastroesophageal Reflux (GERD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 was without cognitive impairment and required extensive assistance with Activities of Daily Living( ADL), and required limited assistance with ambulation and locomotion. The Resident Care Plan (RCP) dated 1/13/20 identified Resident #39 required assistance with bathing, dressing, grooming and hygiene. Interventions directed to gather, provide set-up for all materials, supplies, and equipment needed. Make sure materials and equipment are clean and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of six sampled residents (Resident #98) reviewed for nutrition, the facility failed to notify the consultant dietitian of a significant weight loss and the Advanced Practice Registered Nurse. The findings include: Resident #98's diagnosis included cervical cancer, anxiety, hepatitis, diabetes and anemia. The admission care plan dated 10/30/19 identified a potential for weight loss. Interventions directed to provide a mechanical diet as ordered, educate to eat slowly and to chew each bit thoroughly. Review of Resident #98's weight record identified on 11/3/19 the resident weighed of 130 pounds. The quarterly MDS assessment dated [DATE] identified Resident #98 was without cognitive impairment and required extensive assistance with ADL and supervision with eating. Review of Resident #98's weight on 12/16/19 identified Resident #98 weighed 123.4 pounds. Review of the facility census identified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #9) reviewed for an allegation of mistreatment, the facility failed to ensure their grievance policy was followed. The findings include: Resident #9's diagnoses included anemia, depression and arthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was without cognitive impairment and required extensive assistance with bed mobility and limited assistance with transfer and toileting. Additionally, Resident #9 was frequently incontinent of bowel and bladder. The Social Service note dated 7/19/19 at 9:36 AM identified the care plan team met with Resident #9 and the resident representative for a care plan meeting on 7/18/19. Resident #9 identified a care concern regarding the overnight shift on 7/17/19 that was addressed with administration. Resident #9 remained comfortable and satisfied in long term care. There were no other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for one of five sampled residents reviewed for allegation of abuse (Resident #29), the facility failed to protect the resident from verbal abuse by staff. The findings include: Resident # 29's diagnosis included anxiety, depression, bipolar disorder, hypertension and chronic kidney disease. The annual MDS assessment dated [DATE] identified the resident had intact cognition and required extensive assistance with transfer, dressing, toilet use and personal hygiene. The care plan dated 7/22/19 identified the resident had episodes of anxiety and presented with compulsive thoughts, difficulty concentrating, difficulty falling asleep, excessive worry and restlessness. Interventions directed staff to encourage resident to verbalize thoughts and feelings related anxiety, offer support and reassurance to the resident and family, and provide calm, quiet environment. The nurse's notes dated 7/29/19 noted Resident #29 made social services aware…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #39) reviewed for an allegation of mistreatment, the facility failed to report an allegation of mistreatment to the state agency in a timely manner. The findings include: Resident #39's diagnoses included weight loss, Peripheral Vascular Disease (PVD) and Gastroesophageal Reflux Disease (GERD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 was without cognitive impairment and required extensive assistance with Activities of Daily Living (ADL) including personal hygiene. The Resident Care Plan (RCP) dated 1/13/20 identified assistance was required with ADL. Interventions identified the resident should be allowed sufficient time to accomplish each task, directed to provide privacy as well as dignity and to converse with the resident while giving care. Interview with Resident #39 on 3/02/20 at 1:24 P.M. identified that there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two sampled residents(Resident #39 and Resident # 102) reviewed for Activities of Daily Living (ADL), the facility failed to provide finger nail care for a dependent resident. The findings included: 1. Resident #39's diagnoses included weight loss, Peripheral Vascular Disease (PVD) and GERD. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 was without cognitive impairment and required extensive assistance with ADL including personal hygiene. The Resident Care Plan (RCP) dated 1/13/20 identified assistance with hygiene was required. Interventions directed : to gather, provide, set-up all materials, supplies and equipment needed and to make sure materials and equipment are clean and functioning appropriately. Additionally noted scheduled shower time was on Wednesdays at 9:00 A.M. after breakfast. Observations on 3/2/20 at 11:32 AM and 12:15 PM, on 3/3/20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, facility documentation review and interview for one of two residents in survey sample reviewed for pressure ulcers (Resident#27 ), the facility failed to identify and implement new interventions to prevent the development of a pressure ulcer. The findings include: Resident #27's diagnoses included Multiple Sclerosis (MS). A quarterly (MDS) assessment dated [DATE] identified Resident#27 had no cognitive impairment, was totally dependent with transfers, required extensive assistance with bed mobility and was at risk for the development of pressure ulcers. Resident care plan (RCP) dated 7/10/2019 identified a problem with multiple skin impairments. Interventions included to offer a position change approximately every two (2) hours and as needed. The physician's order dated 9/05/2019 identified that resident refuses all offloading devices implemented for pressure prevention and that the wound MD # 1was aware. The updated 7/10/19 RCP revised on 9/11/2019 identified newly impaired skin on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sample resident (Resident #16) reviewed for Podiatry services, the facility failed to ensure the resident was seen by podiatry in a timely manner. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, malignant neoplasm of the lung, and cancer with chemotherapy. The nurse's note dated 11/12/19 at 2:13 PM identified Resident #16 was seen by APRN for abrasion on left second toe, treatment started and podiatry consultation. A physician's order dated 11/2/19 directed to provide a podiatry consultation for toe nail trim.A physician's order dated 11/14/19 directed to have a podiatry consultation. The care plan dated 11/14/2019 identified at risk for complications of diabetes mellitus. Interventions directed to get a podiatry consultation as ordered. The quarterly MDS assesssment dated 11/30/19 identified Resident #16 had intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two sampled residents for (Resident # 4) reviewed for accidents, the facility failed to ensure an assessment was conducted after a fall and (Resident #16) reviewed for accidents, the facility failed to ensure Resident #16 was supervised during a shower. The findings included: 1. Resident # 4 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarct affecting the right dominant side, muscle weakness, and depression. A Fall Risk Assessment done on admission dated 8/11/19 identified Resident #4 exhibits inadequate knee extension, knee wobble and inadequate toe clearance which were associated with the underlying causes of muscle paresis/weakness and compensatory deviation for a problem elsewhere. Resident #4 had balance problems while standing and walking, jerking or unstable when making turns, and requires use of assistive device. A physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, review of facility policy and interviews for one of six sampled residents (Resident #98) reviewed for nutrition, the facility failed to ensure a re-weight following a significant weight loss, failed to appropriately monitor a resident for intake and output according to a physician's order and failed to ensure appropriate meal provision for a resident with an appointment. The findings included: 1 a. Resident #98's diagnosis included cervical cancer, anxiety, hepatitis, diabetes and anemia. The admission care plan dated 10/30/19 identified a potential for weight loss. Interventions directed to provide a mechanical diet as ordered, educate to eat slowly and chew each bit thoroughly. A review of Resident #98's weight record identified on 11/3/19 the resident weighed 130 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #98 was without cognitive impairment and required extensive assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for one sampled resident (Resident #311) requiring Central Venous Access Device (CVAD) and receiving total parenteral nutrition (TPN), the facility failed to ensure CVAD was consistently flushed per physician's orders and to follow facility policy to prevent possible clogging. The findings include: Resident #311 was admitted to the facility on [DATE] with diagnoses that included intestinal obstruction, malabsorption and anxiety. The care plan dated 2/13/20 identified right chest [NAME] catheter. Interventions directed treatment as ordered. The admission MDS assessment dated [DATE] identified Resident #311 with intact cognition, required limited assistance with bed mobility, transfer and dressing. The physician's order dated 2/12/20 directed TPN total infusion time 18 hours and to flush CVAD with 10 milliliter (ml) 0.9% Sodium Chloride before initiating TPN infusion. Flush CVAD with 20 ml 0.9% Sodium Chloride after TPN infusion has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #16) reviewed for dental services, the facility failed to ensure Resident #16 was seen by dental in a timely. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses that included diabetes, malignant neoplasm of the lung, and cancer with chemotherapy. The quarterly MDS dated [DATE] identified Resident #16 had intact cognition and required extensive assistance of 1 for dressing and bed mobility and supervision with set up personal hygiene and toileting. The nurse's note dated 1/30/20 at 8:21 A.M. identified Resident #16 came to the nursing station with blood in his/her mouth no cut noted, mouth care given. Resident #16 indicated he/she had broken teeth and a gauze was applied to the mouth and bleeding stopped. Additionally, the nurse's note indicated at 3:20 A.M. Resident # 16 was observed sitting on floor near of his/her bed. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation of the kitchen, facility documentation, facility policy, and interviews, the facility failed to ensure garbage containers had lids or covers so waste was properly contained. The findings include: Observation on 3/2/20 at 10:15 AM with the Dietary Supervisor: A. There was a garbage can half full of garbage on the right side of the 3 bay sink without a cover leaning against a stack of dishwasher racks with clean coffee cups in them. There was a second garbage can without a cover on the left side of the sink with a garbage container half full touching against the 5 tier rack with clean pots and pans on it. Dietary supervisor indicated they never had covers for the garbage cans. Interview on 3/4/20 at 2:30 PM with Director of Physical Plant indicated he ordered 2 new garbage cans with lids for the kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for (Resident # 10) the facility failed to dispose of linen to prevent the transmission of infection and one sample resident (Resident # 56) reviewed for Infection Control, the facility failed to follow infection practices by identifying a resident who was on contact precautions for a Multi Drug Resistant Organism and for (Resident # 103), the facility failed to store personal items to prevent the transmission of infection The findings included: 1. Resident #10's diagnosis included dementia with behavioral disturbance, restless and agitated and had cerebral palsy. Observation on 3/4/20 at 10:10 AM identified a pile of linen on the floor at the end of the bed. No facility staff were in the room. Interview and observation with NA #1 on 3/4/20 at 10:12 AM identified that she had thrown the linen on the floor because it was dirty, and Resident #10 was fighting her meaning she was resistive but not refusing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.